Ontario health technology assessment series
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Ont Health Technol Assess Ser · Jan 2004
Video laryngoscopy for tracheal intubation: an evidence-based analysis.
The objective of this health technology policy assessment was to determine the effectiveness and cost-effectiveness of video-assisted laryngoscopy for tracheal intubation. ⋯ Two video-assisted systems are available for use in Canada. The Bullard® video laryngscope has a large body of literature associated with it and has been used for the last 10 years, although most of the studies are small and not well conducted. The literature on the GlideScope® is limited. In general, these devices provide better views of the airway but are much more expensive than conventional direct laryngoscopes. As with most medical procedures, video-assisted laryngoscopy requires training and skill maintenance for successful use. There seems to be a discrepancy between the seeming advantages of these devices in the management of difficult airway and their availability and uptake outside the operating room. The uptake of these devices by non-anesthetists in Ontario at this time may be limited because: Difficult intubation is relatively infrequent outside the operating roomMany alternative and inexpensive devices are availableThere are no professional supports in place for the training and maintenance of skills for the use of these devices outside anesthesia.Video laryngoscopy has no obvious utility in preventing airborne viral transmission from patient to provider but may be useful for teaching purposes.
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The objective of this analysis was to evaluate the effectiveness and cost-effectiveness of the bispectral index (BIS) monitor, a commercial device to assess the depth of anesthesia. Conventional methods to assess depth of consciousness, such as cardiovascular and pulmonary measures (e.g., heart rate, systolic/diastolic blood pressure, mean arterial pressure, respiratory rate, and level of oxygen in the blood), and clinical signs (e.g., perspiration, shedding of tears, and limb movement) are not reliable methods to evaluate the brain status of anesthetized patients. Recent progress in understanding the electrophysiology of the brain has led to the development of cerebral monitoring devices that identify changes in electrophysiologic brain activity during general anesthesia. ⋯ This means an unknown percentage of patients who are already asleep will not be identified because of falsely elevated BIS values. These patients will receive unnecessary dosage of anesthetics resulting in a deep hypnotic state. Adherence to the practice guidelines will reduce the risk of intraoperative awareness.
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The Medical Advisory Secretariat undertook a review of the evidence on the effectiveness and cost-effectiveness of small bowel transplant in the treatment of intestinal failure. ⋯ There is evidence that small bowel transplant can prolong the life of some patients with irreversible intestinal failure who can no longer continue to be managed by parenteral nutrition therapy. Both patient survival and graft survival rates have improved with time. However, small bowel transplant is still associated with significant mortality and morbidity. The outcomes are inferior to those of total parenteral nutrition. Evidence suggests that this procedure should only be used when total parenteral nutrition is no longer feasible.
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Ont Health Technol Assess Ser · Jan 2002
Endovascular repair of abdominal aortic aneurysm: an evidence-based analysis.
The Medical Advisory Secretariat conducted a systematic review of the evidence on the effectiveness and cost-effectiveness of endovascular repair of abdominal aortic aneurysm in comparison to open surgical repair. An abdominal aortic aneurysm [AAA] is the enlargement and weakening of the aorta (major blood artery) that may rupture and result in stroke and death. Endovascular abdominal aortic aneurysm repair [EVAR] is a procedure for repairing abdominal aortic aneurysms from within the blood vessel without open surgery. In this procedure, an aneurysm is excluded from blood circulation by an endograft (a device) delivered to the site of the aneurysm via a catheter inserted into an artery in the groin. The Medical Advisory Secretariat conducted a review of the evidence on the effectiveness and cost-effectiveness of this technology. The review included 44 eligible articles out of 489 citations identified through a systematic literature search. Most of the research evidence is based on non-randomized comparative studies and case series. In the short-term, EVAR appears to be safe and comparable to open surgical repair in terms of survival. It is associated with less severe hemodynamic changes, less blood transfusion and shorter stay in the intensive care and hospital. However, there is concern about a high incidence of endoleak, requiring secondary interventions, and in some cases, conversion to open surgical repair. Current evidence does not support the use of EVAR in all patients. EVAR might benefit individuals who are not fit for surgical repair of abdominal aortic aneurysm and whose risk of rupture of the aneurysm outweighs the risk of death from EVAR. The long-term effectiveness and cost-effectiveness of EVAR cannot be determined at this time. Further evaluation of this technology is required. ⋯ Treatment of an aneurysm is indicated under any one of the following conditions: The AAA is greater than 6 cm in diameter.The patient is symptomatic.The AAA is rapidly expanding irrespective of the absolute diameter.Open surgical repair of AAA is still the gold standard. It is a major operation involving the excision of dilated area and placement of a sutured woven graft. The surgery may be performed under emergent situation following the rupture of an AAA, or it may be performed electively. Elective OSR is generally considered appropriate for healthy patients with aneurysms 5 to 6 cm in diameter. (7) Coronary artery disease is the major underlying illness contributing to morbidity and mortality in OSR. Other medical comorbidities, such as chronic renal failure, chronic lung disease, and liver cirrhosis with portal hypertension, may double or triple the usual risk of OSR. Serial noninvasive follow-up of small aneurysms (less than 5 cm) is an alternative to immediate surgery. Endovascular repair of AAA is the third treatment option and is the topic of this review.